18/63/2887 8:19 9696784996 PAGE 61/67

.
Special Exposure Cohort Petition. U.S. Department of Health and Human Services.
under the Energy Employees Occupational Tiengent o Cantars for Disease Control and Prevention
ness Compensation Act National Institute for ational Safety and Health
OMB Number: 0920-0639. Expires: 05/31/2007

Special Exposure Cohort Petition — Form A Page 1 0f2
DELS TET TTRTRERLNT RMR TERN AETN r aT Era

You should use this petition form only if NIOSH has reported to you in writing that it cannot complete the
dose reconstruction needed for your cancar claim.

All other patitioners should use Petition Form B to submit a petition to NIOSH.

For Further Information: If you have questions about these instructions, please call the following NIOSH
toll-free phone number and request to speak to someone in the Office of Compensation Analysis and
‘Support about an SEC petition: 1-800-366-4674.

NIOSH Claim Information — Complete as much information as you can in Section A,

4 NIOSH Tracking Number (indicated on all NIOSH correspondence):

A.2__ Print Name of Energy Employee for whom this claim was filed:

Mr/MrsJMs. First Name Middle Initial Last Name
A3 Social Securlty Number of Energy Employee for whom this claim was filed:

i

Siqnature of Person Submitting this Petition — Complete Section B.

Print and sign your name below to indicate that you ara petitioning for HHS to consider adding a class
of employees to the Special Exposure Cohort that would inctude the employee indicated by the
tracking number ar name under entry 1 above.

Print your name below. Sign your name below: |

FirstName Middle intial LastName ~ “FirstNgne — Midalo titi] ‘Last Name”

Please send this form to NIOSH at the address below,

Once NIOSH receives this form, the U.S. Department of Heaith and Human Services will consider adding a
class of employees to the Special Exposure Cohort. Your contact at NIOSH will be available to inform you of
the progress of your petition.

Send this form to: SEC Petition
Office of Compensation Analysis and Support
NIOSH
4876 Columbia Parkway, MS-C-47
Cincinnati, OH 45226

Name or Sociel Security Number of First Petitioner.



10/83/2087 98:19 8606784938

PAGE 02/87

Special Exposure Cohort Petition U.S. Department of Health

under the Energy Employees Occupational Centers for Diseqse Control and Prevention
itinass Compensation Act Nationa! Institute for ipational Safety and Health

; OMB Number: 0920-0639 Expires: 05/31/2007
Special Exposure Cohort Petition — Form A Page 2 of 2

ind Human Services

Public Burden Statement

including suggestions for reducing this burden, send them to CDC Reports Clearance
Road, MS-E-11, Atlanta GA, 30333; ATTN:PRA 0920-0639. Do not send the complete

Persons are not required to respond to the information collected on this form unless it d
valid OMB number.

Privacy Act Advisement

following:

The Energy Employees Occupational llinass Compensation Program Act (42 U.S.C. §§|
(EEOICPA) authorizes the President to designate additional classes of employees to b
Special Exposure Cohort (SEC). EEQICPA authorizas HHS to implement its responsibi
assistance of the National Institute for Occupational Safety (NIOSH), an Institute of the
Control and Prevention. Information obtained by NIOSH in connection with petitions for

Board on Radiation and Worker Health and HHS.

Disclosures that NIOSH may néed to make for the processing of your petition or other
below.

NIOSH may need to disclose personal identifying information to: (a) the Department of
agencies, other government or private entities and to private sector employers to perm
retrieve records required by NIOSH; (b) identified witnesses as designated by NIOSH

individuais can provide information to assist with the evaluation of SEC petitions; (c) co}
NIOSH; (d) collaborating researchers, under certain limited circumstances to conduct f

Congressional staff member in response to a verified inquiry.

Public reporting burden for this collection of information is estimated to average 3 minutes per response,
including time for reviewing instructions, gathering the information needed, and complefing the form. if you
have any comments regarding the burden estimate or any other aspect of this collection of information,

address. Completed petitions are to be submitted to NIOSH at the address provided in these instructions.

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. § 552a), you are hereby notified of the

classes of employees in the SEC will be used to evaluate the petition and report findings to the Advisory

Records containing identifiable information become part of an existing NIOSH system of records under the
Privacy Act, 09-20-147 “Occupational Health Epidemiological Studies and EEOICPA P| jogram Records.
HHS/COC/NIOSH.” These records are treated in a confidential manner, unless otherwise compelled by law.
Hurposes are listed

(e) Federal, state and local agencies for law enforcement purposes; and (f) a Member of Congress or a

fficer, 1600 Clifton
petition form to this

splays a currently

7384-7385)
included in the
ities with the
Centers for Disease
including additional

nergy, other federal
these entities to
that these

tractors assisting
ther investigations;

This notice applies to all forms and informational requests that you may receive from N|
with the evaluation of an SEC petition.

Use of the NIOSH petition forms (A and 8) is voluntary but your provision of information

provide required information may not be considered by HHS.

|

forms is mandatory for the consideration of a petition, as specified under 42 CFR Part r Petitions that fail to

OSH in connection

fequired by thase

|

Name or Social Security Number of First Petitioner: